03AS9290Managing the “Unmanageable” Sulcus: Achieving the impossible with basictissue management and Aquasil Ultra Smart Wetting® impression materialJeff T. Blank, DMDPlease Share This Valuable Information With All Doctors, Hygienists, and Assistants in the OfficeIntroduction: subgingival preparations, thin marginal tissue, bulky fibrousThough opinions may vary, it is quite possible that most dentists papilla, as well as the level of osseous crest and tissue attachmentswould agree that the art of impression making could be the most complicate the art of impression taking.important aspect of a successful restorative dental practice. For the It is extremely important that clinicians not only understand theculmination of proper tissue management, cutting a perfect nuances of proper tissue management and retraction, they mustpreparation, gaining proper laboratory support, and ultimately also understand the capabilities of the actual impression materialdelivering a perfectly fitting, properly functioning prosthesis all selected to make the impression. Impression materials varydepend on an accurate impression. Even the slightest inaccuracy in significantly in terms of physical properties, handling capabilities,recording the precise dimensions of the preparation, the and vast differences can exist in the performance of these materials.architecture of the margins, the position of the soft tissue, and the Particularly in difficult, less than ideal clinical presentations.relationship of the prepared teeth to the adjacent and opposingdentition can lead to catastrophic results. In an industry where The purpose of this article is to highlight not only basic tissueprofit margins are shrinking, time is money. And time wasted on management skills, but discuss the key physical properties of apoor field management and inaccurate impression techniques and successful impression material and how both benefit thematerials lead to frustration for the doctor, and patient. practitioner in an everyday clinical setting.Each day, clinicians work in a remarkably difficult environmentthat as a routine is “wet.” This moisture of course is mediated The Basics of Tissue Management:largely by the presence of saliva, but is also generated by crevicular Many clinicians have espoused appropriate, often highlyfluid and hemorrhage products found in the gingival sulcus regimented techniques and materials to manage tissues duringfollowing routine crown and bridge preparations. To deny the crown and bridge procedures. In ideal circumstances, thesepresence of moisture in the sulcus, even when extreme care has methods can control moisture in the gingival crevice and open thebeen taken to assure an optimum field is nonsensical. Most dentists sulcus to permit the creation of an optimum impression withwill agree that by the time a crown is warranted, insults to practically any impression material. The work of Loe, Albers,periodontal health such as longstanding overhangs, open margins, Gendusa, Donovan, Kois, Nemetz, Wilson and many others haverough or irregular emergence contours around direct fillings, served as the keystones for proper tissue management during crownrecurrent or new decay are commonplace, and the resultant and bridge impressions. Preoperative recordings of crestal bonebreakdown of periodontal tissues is widespread. While certainly it height, and determination and preservation of biological width areis admirable to attempt to achieve optimal periodontal health prior requisites for predictable post-delivery tissue height and theto making an impression for every fixed prosthesis, in reality what establishment of a healthy periodontium. While a full discussionis often needed to correct the gingival problem is in fact the on these important concepts is not germane to this paper, theplacement of a well-fitting, properly contoured prosthesis itself. techniques shown in the examples presented here employ these ideals. What is relevant to this discussion is demonstrating aIn addition to controlling moisture in the form of crevicular fluid, predictable way to manage less than ideal soft tissue problemshemorrhage, and saliva, dentists must also create an open, retracted found routinely in common crown and bridge impression taking.sulcus that extends apically beyond the margins of the preparation,and laterally to prevent the soft tissue margin from collapsing onto While many modern all-ceramic systems permit esthetic “invisible”the prepared tooth, occluding access the sulcular area. The amount supragingival margin placement, it is still necessary to place someof retraction possible is highly variable, almost as variable as the margins subgingivally due to the presence of existing restorations orclinical scenarios faced each day by restorative clinicians. Deep decay, or to hide the margin of the more opacious ceramic or Distributed by: Sullivan-Schein Dental is an ADA CERP recognized provider.
metal/ceramic restorations. To deny the frequency by which most The hydrophilicity or “wettability” of an impression material is itspractitioners are required to place margins in the gingival sulcus is ability to develop surface contact with the moist hard and softnot practical. tissues and permit the material to penetrate into the sulcus. Impression materials that show good wettability typically provide better definition of margins in less than dry sulci, and a greater ability to displace moisture and air. If an impression materialThe “Double Cord” Technique: A cannot displace water, blood, saliva or air during an impression, theRequisite for Subgingival Margins positive imprints of the coalesced artifacts lead to voids orThis author advocates the use of a double cord technique when “bubbles” in the impression. The presence of voids can render thefaced with the clinical requirement of a subgingival margin impression useless, and increase the likelihood of retakes.placement. In this technique, as described by Kois, Nementz, Hydrophilicity can be accurately measured by determining theDonovan and others, a small knitted cord is soaked in a plain contact angle, or the degree of arc formed as water is brought inbuffered aluminum chloride solution (Hemodent, Premier Dental) contact with an impression material as visualized in aand gently placed into the junctional epithelium superior to the stereomicroscope. Those materials that possess lower contact anglescrestal connective tissue fibers. This procedure is performed after produce little to no “beading” of water on the surface are“roughing-out” the supragingival preparation, but prior to considered more hydrophilic than materials that demonstrate moresubgingival preparation. Assuming a normal bony crest, anywhere “beading” or higher contact angles. Clinically, it is consideredfrom 1 – 3 mm of apical retraction should occur with this initial optimal for an impression material to be as hydrophilic as possiblecord placement. Once the tissues have reached their ultimate right from the start of the mix; however, there are no good meansretracted position, the preparation is completely to the height of for measuring contact angle on “unset” impression material. Mostthe retracted gingival margin. This can be accomplished effectively modern impression materials use synthetic rubber polymers such aswith full visualization of the margin without lacerating the silicone rubber base or traditional linear polyvinyl siloxane. Onmarginal tissues. The assumption is that once this cord is removed, their own, these materials are hydrophobic (water repelling) andthe tissues will migrate back to their original, more coronal require the use of chemical additives called surfactants to increasepreoperative height, and the margin will become subgingival upon their hydrophilicity. Surfactants are hydrophilic additives that arenormal healing. The preparation is completed and the margins often mixed with hydrophobic materials to make them moredefined. “wettable.” The type of surfactants used in modern impressionIn order to assure lateral retraction of the gingival margin prior to materials is highly proprietary and are not equal in performance.placement of the impression material, a second larger knitted cord Though it may seem logical to simply increase the amount ofsaturated in a buffered aluminum chloride is placed on top of the surfactant in order to make the impression material more wettable,first cord. This cord is left in place for approximately 3-5 minutes, saturating the various chemistries with surfactant diminishes otherand then removed just prior to the placement of the impression. important physical characteristics of the polymers such as tearDuring the impression, the first cord remains in the sulcus, and strength.serves to provide a barrier to continued flow of crevicular fluid or Tear strength is a measure of an impression materials ability tohemorrhage products. resist separation or tearing upon removal from the mouth or stoneUltimately an ideal environment is created with a laterally retracted model. High tear strengths are favorable as this predicts the highersulcus greater than .5mm in width, and more than .5mm of apical likelihood that the impression material will remain intact with noretraction sufficient enough to record an appropriate amount of pieces of separated material remaining in the sulcus or tightunprepared tooth structure apical to the margin. recesses in the stone model upon removal. A medium must be reached such that the impression does not become so rigid that it cannot be removed from the mouth without causing pain or dislodging existing dental restorations or periodontallyThe Role of an ideal Impression compromised teeth, or fracturing delicate intricacies of workingMaterial: casts upon separation from the stone model. While achieving an ideal retracted sulcus is a noble goal, even the Other physical properties such as resistance to deformation andmost meticulous technique can yield a less than ideal environment. percent strain in compression also estimate the rigidity of theIn these circumstances, the physical characteristics of the material. While also influenced by the saturation of certainimpression material are critical. surfactants, these qualities reflect the chemical coupling of theOne physical characteristic of primary importance is hydrophilicity. polymer used and the ability for these materials to crosslink and
remain stable over time. This is where the chemical polymer Case Presentation 1:configuration is extremely crucial, and at least one manufacturer A 27 year oldhas created an entirely unique quadrafunctional polymer which male in perfectoffers significant advantages over previously existing chemistries. medical healthAnother important physical property of impression materials is the presents for arate of viscosity build. All impression materials are two component, full coveragecatalyst/based chemistries that begin as a fluid and gradually turn fixed crown onto a stable solid over a period of time. The rate of this reaction, or tooth #12. Therate of viscosity build, determines several important handling preoperativeproperties of the material. First, the time measured from the start radiographof mix until the time the impression can be removed from the shown in Figure 1mouth is termed the Mouth Removal Time (MRT). In order for an Figure 1 shows the deep radicular decay on distal proximal surfaceimpression material to be useful in dentistry, the clinician must apical to a large amalgam. Endodontic therapy was performed andhave enough working time to get the impression material dispensed a composite core was placed. Since the composite core extendedaround the preparation(s) prior to it “setting” to a point that it will subgingivally and the crown margin must be placed apical to thisno longer flow. Given the varied times required from impressing restoration, it was apparent that a double cord technique would besingle preparations to more sophisticated full arch preparations, required to apically retract the tissues prior to final marginmost impression materials must allow anywhere from 3 – 5 placement. This single, smaller braided cord was placed accordingminutes of MRT. The more advanced materials are now offered in to the guidelines illustrated earlier in the article, and the marginswhat is commonly called "regular" and "fast set" materials and were defined without additional injury to the marginal tissues.offer clinician greater choice in balancing patient comfort with Due to the longstanding presence of bacterial irritants present inadequate working time depending on the clinical situation. the demineralized defect, periodontal breakdown had begun, andThe rate of viscosity build is also critical when more than one the tissues failed to respond favorably to these efforts to completelyviscosity of material is used. While some clinicians prefer to use a stop hemorrhaging and crevicular flow. A second, larger braidedsingle viscosity of material (monophase technique) to record the cord was place to lateral retract the tissues, and a 2% ferric chlorideintricacies of the preparation, sulcus, and the surrounding astringent material was applied to the affected areas. The result wasdentition, other dentists (the author included) prefer to use a lower less than ideal, and upon removal of the second cord, minorviscosity material in the sulcus and around the preparation, and a amounts of hemorrhage persisted (Figure 2).higher viscosity material to record the rest of the dentition and oral The decision wasanatomy (dual phase or tray/wash technique). In the latter, the rate made to test theof viscosity build of both materials used must be matched exactly performance offor a successful impression. If the lower viscosity material has Aquasil Ultrabegun to “set” prior to the placement of the unset more rigid tray Smart Wetting®material, the two viscosities do not flow properly and dragging, Impressionpulling, or folding of the materials occurs. These irregularities may Materialbe obvious upon inspection of the impression, but can go (Dentsply/Caulk)unnoticed by the clinicians. In either case, the result is either a a newretake of the impression, or an improperly fitting restoration. Both quadrafunctional Figure 2of which are inconvenient and often costly to correct. polyvinyl siloxane impression material in this difficult environment. Aquasil Ultra is defined by the manufacturer as a “Smart Wetting”Combining Tissue Management with impression material designed to minimize the problems of voids, 1a Unique Impression Material: bubbles, pulls and drags. In laboratory testing, Aquasil UltraThe following case presentations are illustrated to demonstrate less demonstrated the highest tear strength of 23 leading materials, andthan optimal clinical scenarios in which bleeding and crevicular contact angles as low as 5 degrees – an impressive 8 – 10 timesflow are were difficult to manage. The purpose of of this lower than top competitors. Owed in part to its quadrafunctionaldemonstration is to highlight the advantages of utilizing a new chemistry balanced with a proprietary surfactant, this material isquadrafunctional polyvinylsiloxane impression system. designed primarily with these less than optimal clinical scenarios in 3
mind. Available in an unprecedented 5 viscosities and two different The decision concerning which type of tray (custom tray, stock mouth removal times (3 minute and 5 minute MRT), this material full arch tray, or triple tray) is largely based on the clinical scenario. offers greater choices to suit every impression technique. As The author has had ongoing success with triple trays when limited mentioned earlier in this article, it is the author’s preference to use to 1 – 2 units where the adjacent dentition is intact, good centric a dual phase (wash/tray) technique for cases such as the one occlusion stops are present, and the patient can participate and depicted here. Aquasil Ultra is the first impression material to offer tolerate a closed-mouth impression. When any of these 3 both a Low Viscosity (LV) and Extra Low Viscosity (XLV) requirements are compromised, the other tray techniques are material. Both can yield extraordinary results in capturing the suggested. intricate architecture of the margins, and each are sufficiently The clinical protocol (Figures 4-7) with a dual cord, dual phase hydrophilic to displace the type of moisture found in difficult cases impression technique is as follows: The doctor removes the second such as this. The rate of viscosity build in each of the 5 viscosities larger cord used for lateral expansion of the sulcus, leaving the has been carefully calibrated to minimize pulls, drags and folds. smaller first cord in place completely submerged below the margin. In this case, Aquasil Ultra LV was chosen because the sulcus was The prep is thoroughly rinsed and the sulcus inspected. The doctor well defined and opened sufficiently to allow the flow of a begins syringing the Aquasil Ultra LV into the sulcus while the traditional wash consistency. As compared to the Extra Low assistant is loading the tray with Aquasil Ultra Heavy Body Viscosity (XLV) material, Aquasil Ultra LV is thick enough to DECA™. In this particular case presentation, note in Figure 6 that displace the thick fibrous papilla present in this case. a mild degree of hemorrhage began flowing upon syringing the Aquasil Ultra LV. The impression process begins with the expression of Aquasil Ultra LV into a hand-held syringe with disposable tip. While many practitioners are comfortable with attaching the convenient "wash" tip directly to the gun, the author prefers a shorter, more compact delivery system. This transfer occurs simultaneously with an assistant dispensing Aquasil Ultra Heavy Body tray material into a tray. Coordination of these two steps is very important. As discussed earlier, it is imperative to begin the start times of the Figure 4 Figure 5 dual-phase technique at the same time in order to synchronize the start times for the viscosity build of each system. As with any dual phase impression material, failure synchronize the polymerization start times of both the wash and tray material increases the potential for pulls, drags, and folding. The tray material selected for this case was Aquasil Ultra Figure 6 Figure 7 Heavy Body DECA™, a newly released tray It is in these types of clinical scenarios that the physical properties material dispensed of an impression material are most important. The wettability of conveniently from the Aquasil Ultra Smart Wetting® impression material permits the automated Pentamix® literal displacement of the hemorrhage and crevicular fluid found delivery system in this sulcus. The optimum viscosity at each stage of the (Figure 3). This system impression allow the material to flow into this sulcus without pulls, allows you to fill the Figure 3 drags or voids. tray with the simple push of a button eliminating the “muscle” required by the dental personnel when using typical cartridge/gun delivery systems. While cartridge delivery is popular for lower viscosity materials, dental personnel appreciate the ease and convenience of these automated systems when dispensing heavy bodied materials, especially when filling a large full arch tray. Figure 8 Figure 94
Figures 8, 9 depict the final impression. Note materials, Aquasil Ultra XLV has a more COURSE SPONSORthat with Aquasil Ultra’s significant tear honey-like consistency that flows more readily Sullivan-Schein Dental is course sponsor. Sullivan-Schein Dentals ADA CERPstrength, even those areas where the retraction into thin areas of poor retraction. With its recognition runs from November 2001 tomethods fail to widen the sulcus and only proprietary surfactants, low contact angle even December 2004.thin flanges of the impression material can in blood-soaked fields, and quadrafunctional COURSE CREDITSpenetrate are captured and do not break away polymer coupling, Aquasil Ultra XLV is All participants scoring at least 80% on thefrom the impression. In this less-than- ideally suited for this hostile environment. examination will receive a certificate verifying 3 CEUs. The formal continuing educationoptimum working field, Aquasil Ultra Note in Figure 11 that Aquasil Ultra XLV is program of this sponsor is accepted by thepossessed the required properties to make AGD for Fellowship/Mastership credit. The literally displacing the blood and crevicular current term of acceptance extends fromwhat could be an impossible impression… fluid out of the sulcus as it is syringed around December 2001 to December 2004.possible. Participants are urged to contact their state the preparation. The author admits that this is dental boards for continuing education nearly a hopeless situation for most requirements. impression materials. However, Figure 12 PARTICIPANT FEEDBACK depicts the final result when Aquasil UltraCase Presentation 2: XLV wash material was combined with If any participant wishes to communicate with the author of this course, please fax questionsThis final case presentation depicts a common Aquasil Ultra Heavy Body DECA™ tray to: Sullivan-Schein Dental by fax atscenario in restorative dentistry: The 1-800-781-6337. Be sure to provide us with material. the following information: name, address,unmanageable sulcus. In this case, the patient e-mail address, telephone number, and coursewas taking blood thinner medication to Note that with the exception of the inclusion completed.control longstanding peripheral circulation of actual hemorrhage product into one smallproblems, and therefore had a propensity for area of the impression, Aquasil Ultra Smart COURSE EVALUATIONlonger clotting times even with mild trauma Wetting® impression material was able to We encourage participant feedback pertaining to all courses. Please be sure toto tissues. Though the double cord technique completely capture not only the entire complete the attached survey included withwas employed and copious amounts of margin, but a sufficient flange extension into the answer sheet.astringent were used, the sulcus remained wet this poorly RECORD KEEPING(Figure 10). Postponing the impression after managed Sullivan-Schein Dental maintains recordsachieving ideal periodontal health would be sulcus of your successful completion of any without CE Seminars. Please contact our offices atfruitless as the cause of this bleeding was Sullivan-Schein Dental, Attn.: CEHP, 26600induced by medication and not poor hygiene. tearing, Haggerty Rd., Farmington Hills, MI 48331,The bubbles, by mailing a note requesting a copy of your continuing education credits report. Thisdecision drags or report, which will list all credits earned to Figure 12was made voids. date, will be generated and mailed to you within five business days of receipt.to attemptto capture IMPORTANT INFORMATIONthis The opinions of efficacy or perceived value of any products or companies mentioned inimpressionby Figure 10 Conclusion: this course and expressed herein are those of the author(s) and do not necessarily The purpose of this article was to demonstrate reflect those of Sullivan-Schein Dental.capitalizing helpful tips on successfully impressing the Completing a single continuing educationon the course does not provide enough information “unmanageable” preparation. By combiningSmart to make the participant an expert in the field the unique physical properties of the newly related to the course topic. It is aWetting® combination of many educational courses released Aquasil Ultra Smart Wetting®technology and clinical experiences that allows the impression material with basic techniques for participant to develop the skills, broad-basedfound only managing hemorrhage and crevicular fluid knowledge and expertise related to thein Aquasil subject matter. Figure 11 flow, dentists can simply relax, and count on aUltra. perfect impression. Even under the most COURSE FEE/REFUND POLICYBecause the sulcus was ill-defined and the hostile clinical scenario. The cost for this course is $55.00. Any participant who is not 100% satisfied withfriable tissues were collapsing onto the this course can request a full refund bymargin, the author employed the use of contacting:Aquasil Ultra XLV as the wash viscosity. Sullivan-Schein Dental, Attn: CEHP, 26600 Haggerty Rd.,Compared to traditional wash impression 1. Data is on file at Dentsply Caulk Farmington Hills, MI 48331. 5
Continuing Education Test QuestionsContinuing Education This booklet Answer Sheet on Back of Test Questions Answer Sheet on Back Cover1. In addition to controlling bleeding and 7. A minimum of 0.5mm of unprepared 13. Most synthetic polymers used as the crevicular fluid flow, dentists must tooth structure apical to the margin foundation for impression materials create an open retracted sulcus that must be captured in the impression to are naturally hydrophilic. extends apical to the marginal assure proper emergence profile of a. True position. the fabricated restoration. b. False a. True a. True b. False b. False 14. Quadrafunctional polymers (such as that found in Aquasil Ultra) have2. Preoperative procedures such as the 8. Retraction cords must be placed with greater crosslinking sites and determination of the osseous crest force into the connective tissue increase tear resistance compared height and tissue attachments are not attachment. to linear polymers. important prior to utilizing a double a. True a. True cord technique. b. False b. False a. True b. False 9. In the dual cord technique, gross 15. Failure to synchronize the mixing initial preparation occurs prior to the start times can lead to the creation3. Modern dentists never have to place placement of any cords. of pulls, drags, and voids. crown margins subgingivally. a. True a. True a. True b. False b. False b. False 10. In order to achieve a postoperative4. With a double cord retraction subgingival margin location, the 16. Aquasil Ultra Smart Wetting® technique, both cords are removed final margin is prepared to the Impression Material is at least just prior to making the impression. height of the retracted (1st cord) 8 times more wettable than any gingival margin. other current brand tested. a. True a. True a. True b. False b. False b. False5. Assuming normal crest bone height and a healthy periodontium, the 11. In the dual cord technique, cords 17. If bleeding or continued crevicular apically retracted gingival free must be left in the sulcus for a flow continue after meticulous margin predictably returns to its minimum of 15 minutes to allow attempts to achieve a dry sulcus, preoperative position with atraumatic retraction to occur. there is no impression material cord placing procedures. capable of capturing the impression a. True a. True in this hostile working field. b. False a. True b. False b. False 12. Hydrophilicity (wettability) is6. In the double cord technique, the typically measured by the contact second cord is placed for lateral angle, or the degree of arc formed expansion of the sulcus. as water is brought in contact with a. True an impression material. b. False a. True b. False 7
Managing the “Unmanageable” Sulcus: Achieving the impossible with basic tissue management and Aquasil Ultra Smart Wetting® impression material Jeff T. Blank, DMD CONTINUING EDUCATION ANSWER SHEETName:Address: City:State: Zip: Telephone: Office ( ) Home ( )TO EXPEDITE RECEIVING CE CERTIFICATE, PLEASE PROVIDE E-MAIL ADDRESS:________________________________OR CERTIFICATES SENT BY MAIL WILL BE PROCESSED WITHIN 6–8 WEEKS.1. Completely fill in information and payment section. (Enclose payment)2. Answer sheet must be completed in pen.3. All test questions have only one answer.4. After completing test, mail to: Sullivan-Schein Dental • Attn: CEHP • 26600 Haggerty Rd. • Farmington Hills, MI 48331❑ If you wish to receive your score with your certificate, please check this box.Please direct all questions or requests for more information pertaining to this course to: Sullivan-Schein Dental 1-800-686-4200 x3608.Participants will receive confirmation of passing by receipt of a certificate. Please select one of the following: ❑ Bill to my Sullivan-Schein Dental Account ___________________________________ ❑ Check made payable to Sullivan-Schein Dental for $55.00 is enclosed 3 CE If paying by credit card, please complete the following information: CREDITS ❑ MasterCard ❑ Visa ❑ Discover ❑ American Express Course Fee $55.00 Account # ___________________________ Exp. Date______________ All seminars are invoiced to a Sullivan-Schein Dental account. Course Evaluation Please evaluate this course by responding to the ANSWER SHEET following statements, using a scale of 1. A B 10. A B Excellent=4 to Poor=0. 2. A B 11 . A B 1. The content was valuable: 4 3 2 1 0 3. A B 12. A B 2. The questions were relevant: 4. A B 13. A B 4 3 2 1 0 3. The course gave you a better understanding 5. A B 14. A B of the topic: 4 3 2 1 0 6. A B 15. A B 4. Rate the overall value to you: 7. A B 16. A B 4 3 2 1 0 8. A B 17. A B 5. Would you participate in a program similar to this one in the future on a different topic of interest: 9. A B _____ Yes _____ No Any additional comments: For Internal Purposes Only: JDE # __________________________ Order # __________________________ Check # ____________________